The Hospice Comprehensive Assessment Measure assesses the percentage of hospice stays in which patients who received a comprehensive patient assessment at hospice admission. The measure focuses on hospice patients age 18 years and older. A total of seven individual National Quality Framework endorsed components of quality will provide the source data for this comprehensive assessment measure. These seven measures focus on care processes around hospice admission that are clinically recommended or required in the hospice Conditions of Participation, including patient preferences regarding life-sustaining treatments, care for spiritual and existential concerns, and management of pain, dyspnoea, and bowels.

The numerator of this measure is the number of patient stays in the denominator where the patient received all 7 care processes which are applicable to the patient at admission, as captured by the current Hospice Quality Reporting Program (HQRP) quality measures. To be included in the comprehensive assessment measure numerator, a patient must meet the numerator criteria for each of the individual component quality measure that is applicable to the patient. The numerator of this measure accounts for the three conditional measures in the current HQRP (NQF #1637 Pain Assessment, NQF #1638 Dyspnoea Treatment, and NQF #1617 Bowel Regimen).

The denominator for the measure includes all hospice patient stays enrolled in hospice except those with exclusions.

Patient stays are excluded from the measure if they are under 18 years of age, or are a Type 2 (discharged stays missing the admission record) or Type 3 patient stay (active stays).

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This quality measure is calculated from the Hospice Item Set (HIS) data submitted to CMS under the Hospice Quality Reporting Program (HQRP). All Medicare-certified hospice providers are required to submit HIS data on all patient admissions. Hospices submit two Hospice Item Set (HIS) records (a HIS-Admission record and a HIS-Discharge record) for each patient admission. Timing is not the same for all HIS records, as timing is based on the Admission Date or Discharge Date. Hospice Item Set (HIS) data collection consists of selecting responses to HIS items in conjunction with patient assessment activities or via abstraction from the patient's clinical record. HIS data may be collected on paper forms or using an electronic health record. The HIS may be completed by any hospice staff member, including volunteers, contractors, and affiliates (for example, staff from the quality division of the health system to which a hospice belongs). The hospice is responsible for the accuracy and completeness of information in the HIS. It is at the discretion of the hospice to determine who can accurately complete the HIS.

The Level Of Analysis is performed at the facility level.

Multiple sources: National Quality Forum. (2017). Palliative and End-of-Life Care Off-Cycle Measure Review - Technical Report. Available from: waportal.org/sites/default/files/documents/uw-resources/palliativeoffcyclefinalreport.pdf Partnership for Quality Measurement. (2023). Available from: p4qm.org/measures/0325

NQF specifications available here: www.qualityforum.org/QPS/MeasureDetails.aspx?standardID=1766&print=0&entityTypeID=3

p4qm.org/measures/3235

NQF Measure #3235 (last endorsed on 06 July 2021)